When Therapy Feels Worse Before It Gets Better

A DBT Therapist’s Honest Guide to the Hardest Part of Healing

By Kelly Pinnick, DBT-Linehan Board of Certification, Certified Clinician  |  Southside DBT  |  Telehealth across Georgia

You started therapy because you wanted to feel better. So why, two weeks in, do you feel worse than before you walked in the door?

If you are asking that question right now, this blog was written for you.

The experience of feeling worse at the start of therapy is one of the most common, least talked-about parts of the healing process. And in DBT specifically, it has a very real explanation. Not a vague “it’s part of the journey” explanation. A clinical, neurological, and deeply personal one.

This is not a reassurance piece full of empty phrases like “trust the process.” This is a direct, honest breakdown of exactly why therapy can intensify pain in the early stages, what that means for you specifically in DBT, how to tell the difference between productive discomfort and something that actually needs to change, and what you can do to survive the dip and come out the other side.

Part 1: Why Therapy Can Feel Worse Before It Feels Better

The Numbness Was Doing a Job

Before therapy, most people with significant emotional dysregulation have developed a sophisticated system of not fully feeling things. This system looks different for different people. For some it is constant busyness. For others it is emotional detachment, substance use, or self-harm. For many it is simply a low-grade numbness that has been present for so long it feels normal.

That system was not a flaw. It was survival. When pain is overwhelming and you do not have the skills to manage it, your nervous system finds a way to protect you from the full force of it. Avoidance, suppression, and numbing are the mind’s attempt at self-preservation.

Therapy, and DBT in particular, begins to interrupt that system. Slowly at first, and then more directly. When the system starts to break down, the pain it was protecting you from begins to surface. Not because therapy created the pain, but because the lid is finally coming off.

The Vulnerability Paradox

Therapy asks you to do something that feels fundamentally unsafe: be honest about your pain with another person. For many people who come to DBT, their history has taught them that being vulnerable leads to being hurt, dismissed, or abandoned. So the act of opening up in session, even with a therapist trained in radical acceptance, can trigger exactly the emotional responses the therapy is designed to treat.

You share something painful. Your nervous system interprets the vulnerability as threat. Your emotional brain activates. You leave the session feeling raw, exposed, or flooded.

This is not evidence that therapy is hurting you. It is evidence that the therapy is touching something real.

You Are Now Aware of Things You Were Not Aware of Before

DBT begins with mindfulness for a reason. One of the first things mindfulness practice does is increase your awareness of your internal experience. Before mindfulness training, many people move through their emotional reactions almost on autopilot. Emotions trigger behaviors without a conscious moment in between.

As mindfulness develops, you start to notice what was always there but previously invisible. You notice the shame that arises before the anger. You notice the loneliness underneath the irritability. You notice the anxiety that has been running quietly in the background for years.

Becoming aware of these things is necessary for change. But in the short term, awareness of suffering feels like more suffering. The pain has not increased. Your ability to perceive it has.

The Diary Card Makes Everything Visible

In DBT, you track your emotions, urges, and behaviors on a daily diary card. For most clients, this is the first time in their lives that they have looked directly and systematically at the full scope of their internal experience every single day.

Before the diary card, you might have had a vague sense that your week was hard. After the diary card, you can see exactly how many times you felt suicidal ideation, how many times you acted on self-destructive urges, how many times your emotions spiked above a seven out of ten. That level of visibility can feel overwhelming at first.

The diary card is not creating those experiences. It is making them impossible to ignore. And that visibility, as uncomfortable as it is, is the foundation of genuine change.

Part 2: The DBT-Specific Reasons Feeling Worse Can Mean It Is Working

Here is what no other therapy blog tells you clearly enough: in DBT, there are specific, clinical reasons why increased distress in the early weeks can be a direct sign of progress rather than failure.

Chain Analysis Is Confrontational by Design

When a problematic behavior occurs in DBT, your therapist conducts a behavioral chain analysis. This means you sit down together and trace, in precise detail, every link in the chain from vulnerability factors through to the behavior and its consequences.

This process is uncomfortable. It asks you to relive moments you would rather forget, to sit with the shame or guilt that surrounds a behavior you are trying to stop, and to examine your own role in a sequence you may have preferred to keep unclear.

That discomfort is not a byproduct of chain analysis. It is the mechanism. The clarity that comes from seeing exactly what happened, and exactly where a different skill could have changed the outcome, is how behavioral change actually occurs in DBT. It requires you to look without flinching. And looking without flinching feels terrible at first.

You Are Stopping Behaviors That Were Regulating Your Emotions

Many of the behaviors that bring people into DBT are behaviors that work. In the short term, they reduce emotional pain. Self-harm can provide immediate relief from overwhelming distress. Alcohol blunts emotional intensity. Emotional avoidance keeps you from having to feel what you are not equipped to handle. Rage externalizes pain that feels unbearable when turned inward.

When DBT asks you to reduce or stop these behaviors, it removes the very mechanisms you have been using to manage your emotional experience. Until the new DBT skills are genuinely internalized, there is a gap. The old coping is no longer available, and the new skills are not yet automatic.

That gap is real and it is hard. It is also temporary. But it is one of the most honest things to say about early DBT: for a period of time, you may feel less regulated than before, because the things that were regulating you are being replaced by something more sustainable.

Radical Acceptance Asks You to Feel What You Have Been Avoiding

One of DBT’s core concepts is radical acceptance: the practice of fully accepting reality as it is, without fighting against it or demanding it be different. Radical acceptance is often misunderstood as passive resignation. It is not. It is the active, intentional decision to stop pouring suffering on top of pain.

But here is what that process actually requires: you have to feel the pain you have been fighting against. The fighting was a form of avoidance. When you stop fighting and begin to accept, you move directly into the pain instead of around it.

That is not a comfortable transition. Clients often describe the early stages of practicing radical acceptance as feeling like they are giving up, or as an increase in sadness and grief. They are not giving up. They are grieving. And grieving is a necessary part of moving through something rather than around it.

The Therapeutic Relationship Is Bringing Up Old Relational Patterns

For many people who come to DBT, their history with relationships is complicated. Trust has been broken. Vulnerability has been punished. Closeness has led to hurt. The therapeutic relationship, which is warm and consistent and asks you to be honest and open, can trigger those old relational patterns directly.

You might find yourself feeling suddenly angry at your therapist for no clear reason. Or deeply attached and frightened by that attachment. Or testing the relationship in ways you are not fully aware of. Or convinced the therapist secretly finds you too much, too difficult, too broken.

These are not signs of a bad therapeutic relationship. They are signs that the relationship is real enough to activate old wounds. And working through them in the context of therapy, with a therapist trained in DBT, is part of how those wounds begin to heal.

Part 3: The Timeline of the Dip — What to Expect and When

One of the things that makes early therapy harder than it needs to be is not knowing how long the hard part lasts. Here is an honest, DBT-informed timeline. These are generalizations, not guarantees, but they are grounded in clinical experience.

Part 4: Normal Discomfort vs. Something That Needs Attention

This is the distinction that other guides either skip entirely or handle so vaguely it becomes useless. Here is a direct breakdown:

The left column is hard. It is not pleasant. But it is the expected texture of early DBT work. The right column requires you to tell your therapist directly, in your next session or via phone coaching before then.

DBT’s first treatment priority is always safety. If you are in the right column, that takes precedence over everything else in your treatment.

Part 5: What to Actually Do When You Are In the Dip

Knowing why the dip happens does not make it easy to live through. Here is what genuinely helps during the hardest part of early DBT.

Tell Your Therapist How You Are Feeling

This is the most important thing you can do and also the thing most people avoid doing. Saying to your therapist, “I feel like I am getting worse, not better” is not a sign of failure. It is exactly the kind of honesty DBT is built on. Your therapist needs to know if the current pace is more than you can hold.

A good DBT therapist will not dismiss this. They will use it. They will slow down if needed, increase the support around you, or adjust the approach. The therapeutic relationship is one of the most powerful tools in DBT, but only if you are honest about what is happening inside it.

Use Distress Tolerance Skills, Not Just Emotion Regulation Skills

When you are in the gap phase and emotions are high, attempting complex emotion regulation skills often backfires. When your emotional intensity is above a seven out of ten, the prefrontal cortex that executes those skills is not fully online. This is not a personal failure. It is neuroscience.

What works in high distress are distress tolerance skills: the TIPP skills (Temperature, Intense exercise, Paced breathing, Progressive relaxation), ACCEPTS, and IMPROVE. These do not resolve the emotion. They reduce its intensity enough for you to access other tools.

Do not try to regulate at the peak of a wave. Use distress tolerance to ride it down first.

Keep the Diary Card Even When It Is Painful

The temptation during the dip is to stop tracking. The diary card is confronting because it shows you how hard things actually are. But abandoning the diary card during the most difficult period removes your therapist’s ability to see what is happening and adjust accordingly.

Think of the diary card during the dip as injury documentation. You would not stop measuring your temperature when you are running a fever. The data is most important precisely when things feel worst.

Do Not Increase Session Frequency Without Clinical Guidance

When people feel worse in therapy, a common instinct is to want more sessions. Sometimes this is appropriate. Often, it is not. More sessions without the skills to process what comes up between them can intensify the feeling of being flooded without providing additional relief.

If you feel you need more support, use phone coaching. That is what it is there for. The question to ask is not how do I get more therapy, but how do I use the tools I have been given more effectively in between sessions.

Build Structure Into the Hours After Difficult Sessions

Sessions that go into hard material tend to produce emotional aftershocks. Planning your post-session time in advance reduces the chance of those aftershocks becoming crises. This is a direct application of the DBT skill called Coping Ahead.

A simple post-session plan might look like: do not make major decisions or have significant conversations for two hours after a session. Have a meal. Do something that is predictable and low-demand. Give your nervous system time to come back down before you are required to be fully functional again.

Track Your Progress in Weeks and Months, Not Sessions

Progress in DBT rarely looks like a straight line upward. It looks like a gradual average improvement over weeks and months, with peaks and valleys along the way. If you evaluate your progress after every single session, you will frequently feel like things are getting worse. If you evaluate your progress every four to six weeks, using your diary card as evidence, you are far more likely to see the actual trajectory.

Your therapist will do this with you formally at regular intervals. But you can also begin to notice it yourself. Compare this week’s diary card to the one from six weeks ago. What changed? Even small changes are significant when they are consistent.

Part 6: When Wanting to Quit Is Normal, and When It Is Something Else

Almost everyone in DBT thinks about quitting during the gap phase. This is so common that it is essentially part of the treatment model. Marsha Linehan, who developed DBT and was herself a client before becoming a therapist, wrote extensively about the urge to leave treatment as one of the primary therapy-interfering behaviors.

The urge to quit is worth examining directly rather than acting on immediately.

The Urge to Quit Is Often Emotion Mind Speaking

When the work is hard, emotion mind says: this is not helping, this is making things worse, stop. Emotion mind is not always wrong. But it is short-term in its focus. It does not weigh the cost of quitting against the cost of staying. It registers current pain and seeks immediate relief.

Before acting on the urge to quit, ask yourself: am I making this decision from emotion mind, from reasonable mind, or from wise mind? If the answer is emotion mind, the DBT guidance is to pause the decision, use a distress tolerance skill, and revisit the question when your emotional intensity has decreased.

What Quitting Actually Costs

This is the part of the conversation that requires honesty. If you quit DBT during the gap phase, here is what you are most likely to return to:

• The same emotional patterns, now slightly more entrenched because you know there was an alternative and left
• The same behaviors, possibly intensified by the brief period in which they were being reduced
• A harder time re-entering therapy in the future because the memory of how difficult it was will be the dominant association
• The same life, minus the skills that were beginning to form

This is not said to frighten you into staying. It is said because DBT holds a belief that clients deserve honesty, including honesty about the consequences of their choices. The urge to quit is understandable. The costs of acting on it are real.

When Quitting Is Actually the Right Decision

There are circumstances in which stopping therapy is the correct choice. These include:

• Your therapist is not board-certified in DBT and is practicing a diluted version that does not provide the actual structure you need
• The therapeutic relationship has genuinely broken down in a way that cannot be repaired, and you have attempted to address it directly in session
• You are experiencing iatrogenic harm: meaning the treatment itself is making a documented, clinical condition measurably worse over a sustained period
• Your safety cannot be maintained in outpatient treatment and a higher level of care is needed

If any of these are true, the conversation to have is not with yourself. It is with your therapist directly, or with another mental health professional who can assess your situation.

Part 7: The DBT Reframe That Changes Everything

Here is the central truth of this entire blog, stated plainly:

This is the reframe that clients who stick with DBT through the gap phase almost universally come to understand, usually sometime between months three and six. The pain that therapy surfaces was always there. The numbness that protected you from it was also the numbness that prevented you from building a different life.

DBT’s goal is not to remove all pain from your experience. It is to give you the skills to feel your life fully without being destroyed by it. That requires, at some point, actually feeling it.

The dip is not a detour from healing. In most cases, it is the healing.

Part 8: What the Other Side Looks Like

Here are two real testimonials from Southside DBT clients about what came after the hardest part:

Both of those clients went through the hard part. Neither of them bypassed it. What they built on the other side of it is exactly what DBT describes as a life worth living: not a life without pain, but a life with the skills to carry it.

The Final Word

If you are in the hard part right now, this is what matters most:

1. What you are feeling is real and it makes sense.
2. It does not mean the therapy is failing.
3. It does not mean you are too broken to be helped.
4. It means something is actually happening.
5. The most important thing you can do is tell your therapist what you told yourself when you read this blog.

At Southside DBT, the hard parts of treatment are not treated as problems to manage. They are treated as information, as evidence of engagement, and as the necessary territory that every client who has ever built a different life had to pass through.

You are not going backwards. You are going in.

Crisis Resources: 988 Suicide and Crisis Lifeline: Call or Text 988   |   Crisis Text Line: Text HELLO to 741741